Eight packs of dental instruments from Tan Tock Seng Hospital (TTSH) that had not fully completed the sterilisation process may have been used for outpatient treatment at the hospital's dental clinic. (Photo: AFP/Philippe Huguen)

The employees include senior management and supervisors, NHG said in a statement. The disciplinary action include warnings and financial penalties. They will also undergo retraining and education.

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Up to eight patients who visited the clinic between Nov 28 and Dec 5 may have been treated with instruments that were not steam sterlised, the final step in the sterilisation process, NHG said.

The employees failed to adhere to the “expected requirements of quality and safe care of patients”, said NHG.

HUMAN ERROR

The NHG Review Committee submitted its full investigation report with follow-up actions to the Ministry of Health (MOH) on Tuesday, citing human error as the main cause of the incident.

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“The NHG Review Committee has identified human error with a lapse in adherence to the established sterilisation process and verification protocol as the main cause of the incident,” NHG said in the release.

"In addition, weaknesses in some of the sterilisation protocols and work instructions were found to be contributing factors. There were also gaps in the level of vigilance, NHG said, adding that staff had failed at various points to verify the sterility of the instruments before use.

The Committee also found that the timeliness of incident reporting was “sub-optimal", saying that earlier escalation and faster response could have significantly reduced the impact of the incident.

“We apologise for the lapse, and have started on improvements to ensure that quality and safe care remains paramount in all that we do,” NHG said in the statement.

“Specific recommendations have been made to improve the processes and systems at the TTSH Dental Clinic, including counselling and retraining of its staff," it added.

HOW IT HAPPENED

According to NHG, a TTSH Dental Clinic employee failed to follow established protocol on Nov 28 and loaded packs of instruments into the autoclave machine without initiating the steam sterilisation cycle.

Another staff subsequently unloaded and stored the packs, without realising that the packs had not undergone the final step of sterilisation. These packs were not verified for sterility before use.

It was not till Dec 4 that a TTSH Dental Clinic staff found a dental instrument that had not gone through the final step of steam sterilisation. A physical check of all dental instruments was initiated the next day, and it was confirmed on Dec 7 that eight packs of instruments processed on Nov 28 did not complete the last step of the sterilisation process.

TTSH began contacting 575 patients on Dec 9 to inform them of the incident. Elective procedures at the Dental Clinic were also suspended between Dec 8 and Dec 12 for a safety time-out.

REINFORCING SAFETY CONTROLS

To prevent any recurrence, TTSH has reinforced safety controls across the hospital to “improve vigilance and adherence to processes”, NHG said.

These include strengthening the Dental Clinic’s on-site sterilisation process, ensuring strict adherence to the pre-procedure protocol to check for the sterility of instruments before use, optimising workflow to reduce the probability of human error and strengthening incident reporting frameworks.

Professor Philip Choo, Group Chief Executive Officer of NHG, said: “On behalf of NHG, we sincerely apologise for the incident.

“Patient safety will continue to be our utmost priority, and we hold our staff to the highest standards of quality and safe care of patients. We will work harder to ensure that the well-being and safety of our patients are best served in all our institutions.”

MOH said in a separate statement that it will review the reports and consider if regulatory or other actions are necessary.

“This incident is a timely reminder for all healthcare institutions of the need to maintain a high level of vigilance in delivering patient care safely, and to have a strong reporting and incident escalation culture," MOH said.

"Patient safety is paramount. Following the incident at TTSH Dental Clinic, MOH has instructed all public and private healthcare institutions to further strengthen their systems and ensure staff awareness and strict adherence to all processes for patient safety and care," it added.

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